1. High Prevalence of Sexual Minority Status in a Sample of Women at High Risk for HIV Infection: Associated Individual-level Factors and Sexual Risk Behaviors Tandrea J. Carter, PhD Appalachian State University HPTN Mentor: Carol Golin, MD MPH HPTN Annual Meeting Arlington, VA June 17, 2014

2. Funding for the HPTN 064 study was provided by NIAID, NIDA and NIMH (cooperative agreements UM1 AI068619, UM1 AI068617, UM1 AI068613). The primary author’s work on this manuscript was supported through the HPTN Scholars Program funded by NIAID. ACKNOWLEDGMENTS

3. Background Significant health disparities exist for sexual minority as compared to sexual majority women Greater substance abuse and depression Increased sexual risk behaviors Higher rate of STIs Recent US sexual minority prevalence estimates – 3.5% - 4.3% Few large-scale studies that assess comparative sexual risk behaviors for sexual majority and sexual minority women

4. Objectives 1.Identify prevalence of minority sexual status in HPTN 064 dataset 2.Assess differences between sexual majority and sexual minority women on individual-level factors that have been associated with increased sexual risk 3.Assess differences between sexual majority and sexual minority women on sexual risk behaviors

5. Methods HPTN Women’s SeroIncidence Study (064) N= 2099 Baseline data used for all analyses Variables: Demographics, including sexual orientation Individual-level factors Childhood Abuse Depressive and PTSD Symptoms Substance Use Sexual Behaviors and Partnership Data Unprotected Vaginal and Anal Sex Concurrent Partnerships Exchange Sex Self-Reported Sexually Transmitted Infections

6. Methods Definition of Terms: Sexual Minority = women who identify as lesbian, bisexual, transgender Sexual Majority = women who identify as heterosexual Identity-based definition vs. behavior-based definition Analysis Compared differences in demographic characteristics, individual- level risk factors, and sexual risk behaviors between sexual minority and sexual majority women χ 2 tests and Logistic Regression

7. Results Heterosexual – 1631 (77.7%) Lesbian/homosexual – 35 (1.7%) Bisexual – 348 (16.7%) Other: specify ______ – 25 (1.1%) Unsure – 36 (1.7%) Missing – 25 (1.1%) Other: Specify Recoding: 16 sexual majority, 2 sexual minority, 7 could not be recoded (blank or ambiguous) Sexual Majority: N= 1647 Sexual Minority: N = 385

8. Sexual Majority Sexual Minority P Number of Women1647385 Age (Median)3027<.0001 Education – less than HS36%43%.03 African-American and Non-Hispanic83.7%73.2%<.0001 Employed35.2%37.9%.03 Household Income.005 >10K 20.9%18.4% Refused/Don’t Know/Missing 32.5%41.3% Food Insecurity 44.5%55.6%.0001 Number of Sex Partners – ≥ 255.7%71.7%<.0001 Had concurrent male partners34%48.6%<.0001 Male indirect partners1.8%5.2%<.0001 Table 1 – Comparison of Sexual Minority and Sexual Majority Women on Demographic and Sexual Partner Characteristics

9. Risk Variable OR [95%CI]AOR [95% CI] a Childhood Abuse 1.95 [1.56, 2.45]1.90 [1.51, 2.39] Current Abuse Currently Feel Unsafe 1.68 [1.27, 2.22]1.71 [1.29, 2.27] Emotional Abuse 1.66 [1.32, 2.09]1.63 [1.29, 2.05] Physical Abuse 1.73 [1.34, 2.25]1.72 [1.33, 2.24] Sexual Abuse 1.99 [1.37, 2.89]2.16 [1.48, 3.16] Positive Depression Screen 2.04 [1.62, 2.57]2.12 [1.67, 2.69] Positive PTSD Screen 2.13 [1.69, 2.68]2.20 [1.73, 2.79] Ever Injected Drugs 1.56 [1.07, 2.25]1.74 [1.16, 2.62] Positive Substance Abuse 1.49 [1.16, 1.92]2.00 [1.50, 2.68] Sexual Majority used as reference group a Adjusted for age, African-American ethnicity, and education Table 2 – Comparison of Sexual Majority and Sexual Minority Status on Risk Variables

10. Behavior/OutcomeOR [95& CI]AOR [95% CI] a Anal Sex 1.96 [1.57, 2.45]1.97 [1.56, 2.47] Unprotected Vaginal Sex 0.73 [0.55, 0.96]0.74 [0.56, 0.99] Unprotected Anal Sex 1.87 [1.49, 2.36]1.90 [1.5, 2.41] Self-Reported STI 1.47 [1.06, 2.04]1.41 [1.01, 1.97] Sex for Housing 1.70 [1.29, 2.22]2.02 [1.52, 2.69] Sex for Food 1.51 [1.18, 1.93]1.84 [1.42, 2.38] Sex for Money 1.66 [1.32, 2.09]2.07 [1.62, 2.66] Sex for Drugs 1.29 [0.97, 1.71]1.76 [1.28, 2.41] Sex Worker 2.47 [1.64, 3.73]2.91 [1.89, 4.48] Sexual Majority used as reference group a Adjusted for age, African-American ethnicity, and education Table 3 – Comparison of Sexual Majority and Sexual Minority Status on Sexual Risk Behaviors

11. Exploratory Investigation of Differences between Lesbian and Bisexual Subjects PredictorLesbian OR [95% CI] Current Abuse Sexual Abuse4.36 [1.96, 9.69] Sex for Drugs2.55 [1.22, 5.33] Male indirect partners5.39 [1.86, 15.63] Small number of lesbian-identified participants (N=35) Desire to investigate possible differences between lesbian and bisexual women within sexual minority group Most comparisons were non-significant

12. Discussion and Conclusions Low-income, sexual minority women may be at particular risk for STIs as and high-risk sexual behaviors as compared to sexual majority women Assessing for sexual-identity status may provide important information on sexual risk, even in studies that focus on heterosexual risk behaviors The efficacy and applicability of current prevention efforts for sexual minority women should be investigated to determine if targeted approaches are needed.

13. ACKNOWLEDGMENTS With Profound Thanks to: NIH for funding the ISIS Study All protocol and community teams HPTN 064 (ISIS) was sponsored by Cooperative Agreements UM1 AI068619, UM1 AI068617, UM1 AI068613 from the National Institute of Allergy and Infectious Diseases (NIAID), National Institute of Drug Abuse (NIDA), and the National Institute of Mental Health (NIMH). The content is solely the responsibility of the presenters and does not necessarily represent the official views of NIAID, NIDA, NIMH, or the National Institutes of Health. Tandrea Carter’s work on this manuscript was supported through the HPTN Scholars Program funded by NIAID.